Targeting behavioral factors with digital health and shared decision-making to promote cardiac rehabilitation-a narrative review.

Cardiac rehabilitation (CR) represents an important steppingstone for many cardiac patients into a more heart-healthy lifestyle to prevent premature death and improve quality of life years. However, CR is underutilized worldwide. In order to support the development of targeted digital health interventions, this narrative review (I) provides understandings of factors influencing CR utilization from a behavioral perspective, (II) discusses the potential of digital health technologies (DHTs) to address barriers and reinforce facilitators to CR, and (III) outlines how DHTs could incorporate shared decision-making to support CR utilization. A narrative search of reviews in Web of Science and PubMed was conducted to summarize evidence on factors influencing CR utilization. The factors were grouped according to the Behaviour Change Wheel. Patients' Capability for participating in CR is influenced by their disease knowledge, awareness of the benefits of CR, information received, and interactions with healthcare professionals (HCP). The Opportunity to attend CR is impacted by healthcare system factors such as referral processes and HCPs' awareness, as well as personal resources including logistical challenges and comorbidities. Patients' Motivation to engage in CR is affected by emotions, factors such as gender, age, self-perception of fitness and control over the cardiac condition, as well as peer comparisons. Based on behavioral factors, this review identified intervention functions that could support an increase of CR uptake: Future DHTs aiming to support CR utilization may benefit from incorporating information for patients and HCP education, enabling disease management and collaboration along the patient pathway, and enhancing social support from relatives and peers. To conclude, considerations are made how future innovations could incorporate such functions.

Investigating shared decision-making during the use of a digital health tool for physical activity planning in cardiac rehabilitation.

Background: Shared decision making (SDM) between healthcare professionals and persons with CVD can have a positive impact on motivation, adherence, or sustainability regarding long-term goals and integration of cardiovascular disease (CVD) rehabilitation in the everyday lives of persons with CVD. SDM can foster the transition between regular heart-healthy activity at rehabilitation facilities and more independent activity at home, but it is often challenging to implement SDM given limited time and resources, e.g., in the daily practice of rehabilitation. Digital tools can help but must be appropriately tailored for situated use and user needs. Objective: We aimed to (1) describe in how far SDM is manifested in the situated context when using a digital tool developed by our group, and, based on that, (2) reflect on how digital health tools can be designed to facilitate and improve the SDM process. Methods: In the context of a field study, we investigated how SDM is already naturally applied and manifested when using a digital tool for joint physical activity planning in cardiac rehabilitation in clinical practice. In a two-week qualitative study, we collected data on expectations, experiences and interactions during the use of a digital health tool by seven persons with CVD and five healthcare professionals. Data was collected by means of observations, interviews, questionnaires and a self-reported diary, and analysed with a particular focus on episodes related to SDM. Results: We found that SDM was manifested in the situated context to limited extent. For example, we identified high improvement potential for more structured goal-setting and more explicit consideration of preferences and routines. Based on mapping our findings to temporal phases where SDM can be adopted, we highlight implications for design to further support SDM in clinical practice. We consider this as "SDM supportive design in digital health apps," suggesting for example step-by-step guidance to be used during the actual consultation. Conclusion: This study contributes to further understanding and integration of SDM in digital health tools with a focus on rehabilitation, to empower and support both persons with CVD and healthcare professionals.

Research on Digital Technology Use in Cardiology: Bibliometric Analysis.

BACKGROUND: Digital technology uses in cardiology have become a popular research focus in recent years. However, there has been no published bibliometric report that analyzed the corresponding academic literature in order to derive key publishing trends and characteristics of this scientific area. OBJECTIVE: We used a bibliometric approach to identify and analyze the academic literature on digital technology uses in cardiology, and to unveil popular research topics, key authors, institutions, countries, and journals. We further captured the cardiovascular conditions and diagnostic tools most commonly investigated within this field. METHODS: The Web of Science electronic database was queried to identify relevant papers on digital technology uses in cardiology. Publication and citation data were acquired directly from the database. Complete bibliographic data were exported to VOSviewer, a dedicated bibliometric software package, and related to the semantic content of titles, abstracts, and keywords. A term map was constructed for findings visualization. RESULTS: The analysis was based on data from 12,529 papers. Of the top 5 most productive institutions, 4 were based in the United States. The United States was the most productive country (4224/12,529, 33.7%), followed by United Kingdom (1136/12,529, 9.1%), Germany (1067/12,529, 8.5%), China (682/12,529, 5.4%), and Italy (622/12,529, 5.0%). Cardiovascular diseases that had been frequently investigated included hypertension (152/12,529, 1.2%), atrial fibrillation (122/12,529, 1.0%), atherosclerosis (116/12,529, 0.9%), heart failure (106/12,529, 0.8%), and arterial stiffness (80/12,529, 0.6%). Recurring modalities were electrocardiography (170/12,529, 1.4%), angiography (127/12,529, 1.0%), echocardiography (127/12,529, 1.0%), digital subtraction angiography (111/12,529, 0.9%), and photoplethysmography (80/12,529, 0.6%). For a literature subset on smartphone apps and wearable devices, the Journal of Medical Internet Research (20/632, 3.2%) and other JMIR portfolio journals (51/632, 8.0%) were the major publishing venues. CONCLUSIONS: Digital technology uses in cardiology target physicians, patients, and the general public. Their functions range from assisting diagnosis, recording cardiovascular parameters, and patient education, to teaching laypersons about cardiopulmonary resuscitation. This field already has had a great impact in health care, and we anticipate continued growth.

Outpatient Cardiac Rehabilitation Closure and Home-Based Exercise Training During the First COVID-19 Lockdown in Austria: A Mixed-Methods Study.

OBJECTIVE: To assess the impact of the closure of group-based cardiac rehabilitation (CR) training during the first COVID-19 lockdown in spring 2020 on patients' physical activity, cardiorespiratory fitness, and cardiovascular risk, and to describe the patient experience of lockdown and home-based exercise training during lockdown. DESIGN: Mixed methods study. Prospectively collected post-lockdown measurements were compared to pre-lockdown medical record data. Quantitative measurements were supplemented with qualitative interviews about the patient experience during lockdown. SETTING: Outpatient CR centre in Salzburg, Austria. PARTICIPANTS: Twenty-seven patients [six female, mean (SD) age 69 (7.4) years] who attended weekly CR training sessions until the first COVID-19 lockdown in March 2020. OUTCOME MEASURES: Quantitative: exercise capacity (maximal ergometer test, submaximal ergometer training), cardiovascular risk (Framingham risk score, blood pressure, body mass index, lipids). Qualitative: individual semi-structured interviews. RESULTS: Exercise capacity had significantly reduced from pre- to post-lockdown: mean (SD) power (W) in maximal ergometry 165 (70) vs. 151 (70), p < 0.001; submaximal ergometer training 99 (40) vs. 97 (40), p = 0.038. There was no significant difference in Framingham risk score and other cardiovascular risk factors. Qualitative data showed that almost all patients had kept physically active during lockdown, but 17 (63%) said they had been unable to maintain their exercise levels, and 15 (56%) felt their cardiorespiratory fitness had deteriorated. Many patients missed the weekly CR training and the motivation and sense of community from training together with others. Several patients stated that without professional supervision they had felt less confident to carry out home-based exercise training at high intensity. CONCLUSION: This study highlights the importance of group-based supervised exercise training for patients who engage well in such a setting, and the detrimental impact of disruption to this type of CR service on physical activity levels and exercise capacity. Additionally, learning from the COVID-19 pandemic may inform the development and implementation of remote CR modalities going forward.

[Safety culture in orthopedics and trauma surgery : A qualitative study of the physicians' perspective]. / Sicherheitskultur in der Orthopädie und Unfallchirurgie : Eine qualitative Untersuchung der ärztlichen Perspektive.

BACKGROUND: Hospitals in Germany operate risk management, which can support the prevention of adverse events and to systematically process them. Safety culture is one aspect of this. In German-speaking countries, however, surveying the safety culture is still limited and almost exclusively carried out using quantitative instruments. In Germany, the discipline of orthopedics and trauma surgery is characterized by a high number of confirmed treatment errors and lack of risk clarification, Therefore, this study investigated the safety culture in this discipline. OBJECTIVE: (I) How do orthopedic and trauma surgeons perceive the handling of adverse events in trauma centers and (II) what are relevant components of the safety culture from a medical perspective? MATERIAL AND METHODS: A qualitative study using 14 semi-structured one-to-one interviews was carried out with physicians in orthopedics and trauma surgery. The interviews were audiotaped, transcribed, and analyzed using the thematic analysis by Braun and Clarke and the Yorkshire contribution factors framework. The MAXQDA software was used to organize data. RESULTS: A strong influence of senior staff on the handling of adverse events in the medical team could be determined. It was expected that senior staff members have a strong model role function. They were expected to exemplify a high safety culture, because their behavior influences the team's behavior in patient safety-related situations. CONCLUSION: The involvement of senior staff in the development of interventions to improve the safety culture in orthopedics and trauma surgery should be considered due to the importance of hierarchical structures.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]. / "Terror awareness" bei Humanmedizinstudierenden im 5. Jahr des Mannheimer Reformierten Curriculums Medizin plus.

BACKGROUND: The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar. METHODS: All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students. RESULTS: A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism. CONCLUSION: With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.